Predicting the risk of hyperkalemia in patients with chronic kidney disease starting lisinopril

Abstract

Purpose Angiotensin-converting enzyme (ACE) inhibitors are recommended for patients with chronic kidney disease (CKD) because they slow disease progression. But physicians’ concerns about the risk of hyperkalemia (elevated serum potassium level), a potentially fatal adverse effect, may limit optimal management with ACE-inhibitors. We synthesized known predictors of hyperkalemia into a prognostic risk score to predict the risk of hyperkalemia. Methods We assembled a retrospective cohort of adult patients with possible CKD (at least one estimated glomerular filtration rate (eGFR) value less than 60 mL/min/1.73m2) who started an ACE-inhibitor (i.e., incident users) between 1998 and 2006 at a health maintenance organization. We followed patients for hyperkalemia: (1) potassium value > 5.5 mmol/L; or, (2) diagnosis code for hyperkalemia. Cox regression synthesized a priori predictors recorded in the electronic medical record into a risk score. Results We followed 5,171 patients and 145 experienced hyperkalemia, a 90-day risk of 2.8%. Predictors included: age, eGFR, diabetes, heart failure, potassium supplements, potassium-sparing diuretics, and a high dose for the ACE-inhibitor (lisinopril). The risk score separated high-risk patients (top quintile, observed risk of 6.9%) from low-risk patients (bottom quintile, observed risk of 0.7%). Predicted and observed risks agreed within 1% for each quintile. The risk increased gradually in relation to declining eGFR with no apparent threshold for contraindicating ACE-inhibitors. Conclusions The risk score separated high-risk patients (who may need more intensive laboratory monitoring) from low-risk patients. The risk score should be validated in other populations before it is ready for use in clinical practice.

Life‐threatening drug‐associated hyperkalemia: a retrospective study from laboratory signals

“…Our findings are consistent with those of earlier studies concerning drug‐induced hyperkalemia . Despite methodological differences, some characteristics were usually found regarding co‐morbidities such as diabetes, renal injuries or older age .…”

“…Drugs more frequently involved were spironolactone, ACE inhibitors and ARAs . The concomitant use of several drugs known to increase serum potassium concentration was also described …”

Hyperkalemia Associated with Use of Angiotensin‐Converting Enzyme Inhibitors and Angiotensin Receptor Blockers

“…ACEi/ARB therapy is considered a contributing cause in 10% to 38% of hospitalized hyperkalemia cases [27,57,59,60]. In ambulatory practice, ACEi/ARB therapy also contributes to hyperkalemia in up to 10% of patients [35,48,58,61], with about 1% of patients with diabetes experiencing serious hyperkalemia [58]. Furthermore, ACEi/ARB therapy is implicated in hyperkalemia in as many as 6% of patients enrolled in clinical trials [2,37,62,63].…”

Sodium Zirconium Cyclosilicate (ZS-9): A Novel Agent for the Treatment of Hyperkalemia

“…Impaired kidney function is the major risk factor seen in patients in the emergency department and is present in 33–83% of all cases of hyperkalemia . Medications such as renin‐angiotensin‐aldosterone system (RAAS) inhibitors, either alone or in combination with other factors, account for 35–75% of cases …”